Drug Interactions with Directly Acting

Antivirals for HCVAlice Tseng, Pharm.D., FCSHP, AAHIVP

Toronto General HospitalFaculty of Pharmacy University of Toronto

Overview and Challenges in HIV/HCV Co-Infection

Outline Understand how the pharmacology of

DAAs contribute to drug interactions Highlight important HCV drug

interactions Outline a strategy for identifying and

managing drug interactions Identify pertinent HCV drug interaction

resources

Boceprevir and Telaprevir Pharmacology

Boceprevir TelaprevirDosing 800 mg q8h

with food750 mg q8h with food (20 g fat)

Substrate

CYP3A4, P-gp, AKR

CYP3A4, Pgp

Inhibitor

3A4, P-gp 3A4, P-gp, renal transporters (?)

Inducer No inducing effects in vitro (in vivo?)

potential for interactions with other drugs• can be clinically significant• sometimes unpredictable

Interactions Between HCV & HIV Medications

Multiple challenges in treating HIV/HCV co-infected patients

Additive toxicities: anemia: ribavirin, zidovudine, DAAs CNS effects: interferon, efavirenz

Altered concentrations of ARVs and/or DAAs: risk of toxicity efficacy, potential development of

resistance (HIV and/or HCV)

Telaprevir 750 mg q8h plus Boosted PIs in Healthy Volunteers

Telaprevir exposure with PI/r

AUC 20-54%

Cmin 15-52%

van Heeswijk et al. CROI 2011, #119

Telaprevir 750 mg q8h plus Boosted PIs in Healthy

Volunteers Telaprevir

had variable effect on PIs: 40-47%

AUC of DRVr, FPVr

n/c with ATVr, LPVr

Appropriate doses not yet established

van Heeswijk et al. CROI 2011, #119

Two-Way Interaction between Boceprevir and Boosted PIs

Interaction studies in healthy volunteers

Coadministration of boceprevir and ritonavir-boosted PIs is not recommended

PI Kinetics RTV AUC BOC AUC

Ctrough AUC CmaxATVr 49% 35% 25% 34% -DRVr 59% 44% 36% 27% 32%LPVr 43% 34% 30% 22% 45%

Hulskotte et al. CROI 2012, #771LB

Interactions Between HCV DAA & NNRTIs

Summary of Healthy Volunteer Studies

Dosing recommendations on using HIV non-nucleoside reverse transcriptase inhibitors (NNRTIs) with HCV directly acting antivirals: Efavirenz: avoid with boceprevir, use 1125 mg TID

telaprevir Etravirine: ? with boceprevir, OK with telaprevir Rilpivirine: OK with telaprevir

van Heeswijk et al. CROI 2011, #119. Garg et al. 6th HCV PK Wksp 2011, #PK_13. Victrelis Monograph 2011. Hammond et al. IWCPHT 2012 O-15. Kakuda et al. IWCPHT 2012 O_18

Efavirenz Etravirine Rilpivirine-40%

-20%

0%

20%

40%

60%

80%

100%

-10%

-3%

93%

-29%

Impact on NNRTI Cmin

BoceprevirTelaprevir

-44%

-25%

-12%

-25%

-13%

-50%

-40%

-30%

-20%

-10%

0%

Efavirenz Etravirine Rilpivirine

Impact on HCV DAA Cmin

Boceprevir Telaprevir

No Clinically Significant Interaction with Raltegravir and Boceprevir or Telaprevir

Mean Telaprevir PK +/- RAL

Mean Raltegravir PK +/- Telaprevir

de Kanter et al. CROI 2012, #772LB. van Heeswijk et al. ICAAC 2011, #A1-1738a.

with TVR: RAL 78% Cmin, 26% Cmax, 31% AUC

Mean Raltegravir PK +/- Boceprevir

In the presence of raltegravir, boceprevir exposures were similar to historical controls

Antiretroviral Treatment Options in HCVBoceprevir Telaprevir

PIs Avoid with PIr Avoid DRVr, FPVr, LPVr

Possible ATVr???? ATVr OK

Avoid EFV Dose with EFV

NNRTIs Etravirine (?) Etravirine OKNo data Rilpivirine OK

InSTIs Raltegravir OK

Elvitegravir/cobicistat: no data (???)

Maraviroc No data potential / MVC; potential benefit on fibrosis?

NRTIs Tenofovir OKAvoid AZT (anemia)

DAA Interactions with Other Drug Classes

Antidepressants Methadone Benzodiazepines Cardiovascular Drugs Transplant Drugs

Treatment of Depression in HCV Patients with HCV may require antidepressant

therapy Escitalopram is considered a first-line option

no interaction with boceprevir 35% AUC with telaprevir, may need to titrate dose

Agents which are partially metabolized via CYP3A4 may theoretically be by DAAs e.g., desvenlafaxine, venlafaxine, sertraline,

mirtazapine, imiprimine combinations not studied, clinical significance

unknown Low risk of interactions predicted with bupropion,

tricyclic antidepressants, some SSRIs

Methadone Interactions

Boceprevir interaction: R-methadone AUC 16%,

Cmax 10%; no withdrawal

Telaprevir interaction: R-methadone Cmin 31%,

Cmax 21%, AUC 21%, but median unbound Cmin was unchanged, no withdrawal Sx

Hulskotte et al. 2012, Van Heeswijk et al. 2011.

Methadone is metabolized by CYP2B6, CYP2C19 & CYP3A, 85% protein bound; R-isomer is biologically active enantiomer

Benzodiazepine InteractionsMajority are substrates of CYP3A4

risk for prolonged/excessive sedationOral midazolam & triazolam are contraindicated

with boceprevir and telaprevir 5 to 9-fold midazolam AUC with boceprevir or

telaprevir IV midazolam: consider dose, close monitoring

for respiratory depression or prolonged sedation Other benzodiazepines: dose and monitor Consider using benzodiazepines that are

glucuronidated: lorazepam, oxazepam, temazepam

Using Statins with Boceprevir or Telaprevir

Boceprevir Telaprevir

Lovastatin, Simvastatin

CONTRAINDICATED

Atorvastatin May need to atorvastatin dose; do not exceed >20 mg/d

CONTRAINDICATED

Pravastatin Start with recommended dose and monitor for toxicity.

Possible in statin; use with caution.

Rosuvastatin, Fluvastatin

Possible in statin; use with caution.

Victrelis & Incivek Product Monographs, 2011; FDA HIV/AIDS Update, 2012.

Use lowest statin dose and titrate slowly to response

Effect of Steady-State Telaprevir on the Pharmacokinetics of Amlodipine 5 mg

Calcium channel blockers (CCBs)

Amlodipine, diltiazem, felodipine, nifedipine, nicardapine, verapamil are CYP3A4 substrates

Concentrations may be by boceprevir or telaprevir

Use with caution, clinical monitoring

Consider dose reduction

Lee et al. Antimicrob Agents Chemother 2011.

amlodipine AUC 179% monitor for dose-related

toxicity

Interactions between DAAs and Transplant Drugs

Cyclosporine & tacrolimus are CYP3A4 substrates; significant concentrations with DAAs: cyclosporine: AUC 2.7-fold with boceprevir,

4.64-fold with telaprevir tacrolimus: AUC 17.1-fold with boceprevir,

70.3-fold with telaprevir

CsA and TAC dosing with telaprevir coadministration: CsA: from 200 mg to 25 mg daily (n=7) TAC: to 50% dose given weekly (n=7)

Hulskotte et al. HEP DART 2011, poster 123. Garg et al. Hepatology, 2011. Mantry et al. HEP DART 2011, #90. Kwo et al. EASL 2012, #202.

Drugs Contraindicated with Boceprevir and Telaprevir (1)

1-adrenoreceptor antagonist

alfuzosin hypotension, cardiac arrhythmia

antiarrhythmics Quinidine, propafenone, amiodarone.Flecainide (TVR)

serious/life-threatening cardiac arrhythmia

antimycobacterials Rifampin Loss of virologic responseErgot derivatives Acute ergot toxicityHerbal product St. John’s wort Loss of virologic responseStatins Lovastatin,

simvastatin.Atorvastatin (TVR)

Myopathy including rhabdomyolysis

neuroleptic Pimozide serious/life-threatening cardiac arrhythmia

Victrelis & Incivek Product Monographs, 2011

Drugs Contraindicated with Boceprevir and Telaprevir (2)

PDE-5 inhibitor sildenafil.tadalafil (BOC); vardenafil (TVR)

Visual abnormalities, hypotension, prolonged erection, syncope

Sedatives/ hypnotics

oral midazolam, triazolam

Increased sedation or respiratory depression

Other cisapride, astemizole, terfenadine

serious/life-threatening cardiac arrhythmia

Anticonvulsants(BOC)

carbamazepine, phenytoin, phenobarbital

Loss of virologic response

OC (BOC) drospirenone hyperkalemiaAldosterone antagonist (TVR)

eplerenone hyperkalemia

Triptans (TVR) eletriptan Coronary artery vasospasm, MI, vent. tachycardia, VF

Victrelis & Incivek Product Monographs, 2011.

Summary Potential for numerous interactions between

DAAs and ARVs, as well as agents prescribed by other providers challenge in treating HIV/HCV coinfected patients,

particularly in context of earlier cART initiation, aging population and management of comorbidities

Steps to minimizing/managing interactions: ensure medication records are up to date at each visit utilize pertinent drug interaction resources to identify

combinations of potential concern consult with physicians & pharmacists with expertise in

HIV and HCV institute therapeutic plan with close monitoring

HIV & HCV Drug Interaction Resources

Interactions in HCV and HIV: Kiser J et al. Hepatology 2012;55:1620-8. Tseng & Foisy. Curr Infect Dis Rep

2012;14:67-82.

Internet Toronto General Hospital Immunodeficiency

Clinic; www.hivclinic.ca, www.hcvdruginfo.ca

Liverpool Pharmacology Group; www.hep-druginteractions.org